From MSN ~ Wednesday, October 06, 1999

More than one in four people who see chiropractors are seeking relief from neck pain. Chiropractic: Does it work? Experts say yes By Susan Ince SPECIAL TO MSNBC

Oct. 6 — Despite a spell of negative publicity for chiropractic medicine, the practice has never been more popular: The number of chiropractic visits per capita has doubled in the past 20 years. Do chiropractors offer more than just a good back rub? Experts say yes.

WITHOUT AN ACCIDENT or unusual exertion to explain it, two years ago Debra Levy, then 32, suddenly found herself immobilized by excruciating pain in her lower back. Muscle relaxants were prescribed but didn’t help. A few days later the pain was so severe she was taken from her home by ambulance and hospitalized overnight.

X-rays showed inflammation but no bulging discs or other structural abnormalities, and physicians sent her home with stronger painkillers and instructions to rest and wait for the situation to improve. Levy spent most of the time flat on her back; when she walked at all, her body was contorted into an L-shape.

Then, with her physician’s support, Levy began to see chiropractor Linda S. Squires, president of Amethyst Chiropractic in Brookline, Mass. There, Squires readjusted her spine and pelvis, massaged the muscles to help release spasms and gave Levy careful instructions on stretching her muscles and using her back properly.

“Instead of waiting for the inflammation to dissipate and the spasms to let go, we manually work the muscles and adjust the spine and pelvis so there is a quicker recovery time,” says Squires. “Then we lessen the frequency of treatments and try to move people to independence.”

Levy says the approach got her out of bed and quickly back to work as a youth manager for the AIDS Action Committee of Boston.

“She took me from a crisis stage — having this unknown painful awful problem — and explained what was wrong. Learning small things, like how to sit and get up safely, made me feel more in control of my healing,” says Levy. After about a month of regular adjustments, Levy’s visits tapered off, and within a few months she was able to enjoy a long-planned kayaking trip to Mexico.

Now, Levy recognizes early signs of trouble and returns to Squires for occasional adjustments and advice — most recently, after adopting a baby and having a back flare-up before she learned the proper mechanics for lifting and changing the infant.

Levy’s experience illustrates why chiropractic is so popular: It is usually used for neuromuscular conditions where evidence is most solid and no treatment option works perfectly. While there’s little evidence supporting the use of chiropractic for conditions like asthma or stomach troubles, experts say studies show the discipline does offer relief — especially to patients with back pain, sore necks and headaches.

Though it’s unclear just how chiropractic works, one theory holds that it mobilizes the spinal joints to improve the function of the nerves exiting the spine at different levels.


BAD BACKS

Several years ago, the U.S. Agency for Health Care Policy and Research concluded that chiropractic care is effective in the first month of low back symptoms.

And Americans are paying attention. One in six U.S. adults uses chiropractic services, according to a survey of 1,500 adults commissioned by Landmark Health, Inc., of Sacramento, Calif. About 38 percent of these patients seek care for low back pain, according to an American Chiropractic Association survey.

What are chiropractors?
		And what do they do? • Chiropractors specialize in the treatment of the musculo-skeletal system. Classic chiropractic treatment involves manipulation of the bones and joints, primarily of the spine. • They may also use massage or other techniques to loosen tight muscles. • In addition, chiropractors often suggest exercises or educational materials on proper ergonomics to help a patient safely return to normal activities as soon as possible.

“The preponderance of the evidence strongly suggests that for acute lower back pain, without evidence of neurologic deficit, the treatment of choice is spinal manipulation,” says John J. Triano, a chiropractor and co-director of conservative medicine at the Texas Back Institute in Plano.

If low back pain is accompanied by worsening leg weakness, spreading numbness or loss of bowel or bladder control, however, patients should seek prompt evaluation by a physician, says Triano.

“The other major consensus is that if someone goes to a chiropractor and feels no better after 10 to 12 treatments, then additional treatment of the same time will probably not be of great benefit. If you’re not better after four to six weeks, there’s no point in flogging a dead horse and going with the same type of treatment — and that is also true of acupuncture, medication or whatever you decide to try,” says Dr. Scott Haldeman, a clinical professor of neurology at the University of California-Irvine and a specialist in spinal problems.

At the Texas Back Institute, having a range of professionals working together makes it easier to identify treatments that are failing and switch patients to something else, says Triano, who receives five calls a month from orthopedists and chiropractors hoping to establish similar relationships. However, Triano cautions that a one-time cure for low back problems is unrealistic. Like Levy, most people will experience a periodic return of symptoms — on average having their second episode about seven months after the first.

“Studies are beginning to provide strong evidence that manipulation can relieve symptoms and restore function faster in people with chronic back problems. But probably the most bang for the buck is for people with back problems to make lifestyle changes and become very physically fit,” says Triano.


PAINS IN THE NECK

More than one in four people who see chiropractors are seeking relief from neck pain, whether it stems from an injury or from daily misuse and bad posture — say, sitting for hours in front of a computer screen or using the neck to cradle the telephone.

In general, the medical model has not been successful in addressing neck pain, according to Triano.

“Whether you see a chiropractor, an orthopedist or a neurologist, there is no good system to pinpoint the specific pain-generating tissue and provide a specific treatment for neck pain, unless there is severe trauma with obvious dislocations or fractures,” says Triano. “At this point, the evidence shows that manipulative procedures are worth the effort, but if you are not responding well after two to four weeks, it is probably not the right treatment.”

Choosing a chiropractor
		Dr. Scott Haldeman, a clinical professor of neurology at the University of California-Irvine and a specialist in spinal problems, offers these tips:
		•	Be careful, as you would with any physician, not to go to someone with claims that exceed logic.
		•	Expect a thorough physical examination before treatment.
		•	Expect a reasonable and understandable explanation of what the chiropractor thinks is wrong and what you can expect from the treatment.

The most common acute cause of neck pain is whiplash — the term used for the painful symptoms created when a sudden insult, such as a rear-end collision, forces neck structures to extend past their normal range of motion.

“The amount of data is not as strong as for low back pain, but a recent coalition in Quebec felt that chiropractic is a reasonable option in the treatment of whiplash,” says Haldeman.

Immediately after a whiplash, patients generally do better if they are encouraged to move their necks gently and return to normal activities as quickly as their pain will permit, says Triano, who reserves the use of collars to those patients with severe bruising and soft-tissue damage.

Whether manipulation soon after an injury helps is debatable. One study, described in a RAND corporation analysis, found that manipulation resulted in immediate improvement. But one week later, it was no better than encouraging patients to move their necks.

“Manipulation is probably most effective in subacute neck pain, when the patient is over the initial injury but the neck is still subject to muscle spasms, limited range of motion and ‘locking up,’” comments Haldeman.


CAN MIGRAINE BE MANIPULATED?

About 14 percent of chiropractic patients are looking for headache relief, according to the American Chiropractic Association.

Recently, researchers at the Northwestern College of Chiropractic in Bloomington, Minn., compared the use of spinal manipulation against daily treatment with amitriptyline — a tricyclic antidepressant used in the preventive therapy of both chronic tension and migraine headache. In their study of 218 patients with frequent migraine (at least four episodes per month), scores derived from patients’ daily headache pain diaries improved between 40 and 50 percent over the four-week treatment period, whether the treatment was twice-weekly chiropractic adjustments, amitriptyline or both.

However, four weeks after the treatments were stopped, those in the chiropractic group retained the benefits, while those in the amitriptyline and combined groups lost about half of their improvement, according to a report in the Journal of Manipulative and Physiological Therapeutics.

“The results were virtually identical to a similar study, without the combination group, that we conducted with tension headache,” says lead author Craig F. Nelson, a chiropractic and clinical researcher at the Northwestern College of Chiropractic.

“I would caution that overaggressive manipulation of the neck can actually make migraine worse. However, less vigorous manipulative techniques, especially when combined with an active exercise program, can be beneficial for many migraine sufferers,” says Frederick G. Freitag, a chiropractic and associate director of the Diamond Headache Clinic in Chicago.

Red flags
		While there are many benefits to manipulation, there are some situations in which the technique should be avoided, such as if a patient has:
		•	Acute severe injuries
		•	A fracture
		•	Cancer
		•	A tumor or softening of the bone, unless cancer has been ruled out
		•	Severe rheumatoid arthritis
		•	Tuberculosis
		•	Severe spinal infection
The Agency for Health Care Policy and Research; Dr. Scott Haldeman

Whatever treatments they use for migraine, patients should work with health care providers to identify the triggers that provoke their headaches, and avoid the daily or almost daily use of pain relievers, which can result in rebound headaches, says Nelson.

“It’s unrealistic that there will ever be a single gold-standard treatment for chronic headaches. There are probably several dozen treatments, including medication, chiropractic and others, that can be effective — but for a given individual it is not clear which is likely to be the best. Whatever the treatment is, the patient should expect a good result. After four to six weeks, move on if the results and the side effects are not acceptable,” concludes Nelson.

“Some patients do have postural or mechanical factors that contribute to their headache situation. In that kind of patient, it can occasionally be useful to use manipulative therapies such as chiropractic or physical therapy, along with exercise conditioning programs or postural retraining programs to address the underlying problem,” says Freitag.

Although some chiropractors tout the technique’s benefit in asthma, menstrual distress, recurrent ear infections and gastrointestinal symptoms, only a small percentage of its patients are seeking treatment for conditions without a clear musculo-skeletal component. Given the state of the existing research evidence, that makes sense, says Nelson.

“I think it’s fair to say that chiropractors are trained to evaluate and manage neuro-musculo-skeletal disorders conservatively and to know when conservative treatment is no longer appropriate,” Nelson says.

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Susan Ince is a medical writer based in Hawaii. She has contributed to many national publications, including Glamour, American Health, Redbook and Good Housekeeping.

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